MULTIPLE CHOICE QUESTIONS —PREPARATORY TEST

MULTIPLE CHOICE QUESTION —PREPARATORY TEST

Here’s a possible set of keys or codes for the multiple-choice questions:

1. c = Correct

2. u = Unsatisfactory

3. a = Acceptable

4. h = Potentially harmful

Per each options of the questions, the above keys or codes will be written against them indicating for instance; the correct answer , unsatisfactory, acceptable or potentially wrong of harmful option..

1. A patient with hypovolemic shock would most likely exhibit which of the following signs?

A. increased CVP; decreased BP; increased pulse rate

B. decreased CVP; decreased BP; increased pulse rate

C. increased CVP; increased BP; decreased pulse rate

D. decreased CVP; increased BP; decreased pulse rate

EXPLANATIONS:

B. Hypovolemic shock is a condition with a decrease in the amount of circulating blood volume in the intravascular system. A decrease in the amount of circulating volume will result in a decrease in the CVP pressure which is an indirect measurement of the amount of blood in the right ventricle. Less blood in the vascular system means decreased blood pressure. Since there is less blood in the circulation, the body will attempt to compensate for this by increasing the number of contractions (pulse rate) and the force of those contractions due to increased sympathetic stimulation.

2. Examination of the heart in chronic heart failure frequently reveals

A. S3.

B. splitting of S2.

C. paradoxical splitting of S2.

D. holosystolic murmur.

EXPLANATIONS:

(c) A. S3 occurs as a result of the left ventricle becoming stiff and interfering with blood entering the left ventricle during filling. As the left ventricle loses its compliance, there is impaired filling which results in less blood entering the left ventricle, increased left ventricle filling pressures, and left ventricular failure .Contraction of the left ventricle is not initially affected, but becomes affected with time

3.Which of the following conditions is most suggestive of an asymptomatic abdominal aortic aneurysm?

A. abdominal mass

B. hypertension

C. chest pain

D. syncope

EXPLANATIONS: Explanations play a vital role in providing clarity and understanding. When it comes to conveying complex ideas or concepts, clear and concise explanations are crucial. An explanation can be defined as the process of making something clear or understandable by providing details, reasoning, and examples. It serves as a bridge between the unknown and the known, helping individuals to comprehend information and make informed decisions. In various fields, such as education, science, technology, and business, explanations are an integral part of the learning and problem-solving processes. Teachers use explanations to impart knowledge, while scientists use them to describe phenomena and theories. In education, explanations facilitate learning by breaking down complex topics into digestible components. By using language that is accessible and relatable, educators can engage students and enhance their understanding. In scientific research, explanations are essential for presenting findings to the broader scientific community. Utilizing clear and concise language, scientists can explain their methodologies, results, and conclusions, enabling others to build upon their work and contribute to the advancement of knowledge. Explanations are also valuable in the field of technology. From user manuals to troubleshooting guides, clear explanations ensure that individuals can effectively utilize and troubleshoot devices and software. By providing step-by-step instructions and addressing common issues, technology companies empower users to make the most out of their products. Moreover, in the business world, explanations are crucial for communicating strategies, processes, and policies. Whether it’s explaining the rationale behind a new marketing campaign or outlining the steps of a business procedure, clear explanations foster transparency and alignment within organizations. Overall, explanations are powerful tools for promoting understanding and facilitating communication. By utilizing language effectively and providing clear and coherent explanations, individuals can bridge knowledge gaps and ensure that information is accessible to all.

4.Post-infarction syndrome (Dressler’s syndrome) occurs after acute myocardial infarction presenting as

A. ventricular aneurysm.

B. pericarditis and pleuritis.

C. cardiac tamponade.

D. pleural effusion and rash.

EXPLANATIONS:

5.The typical physical examination finding of scarlet fever is which of the following?

A. slapped cheek appearance

B. strawberry tongue

C. Koplik’s spots

D. honey-crusted lesions

EXPLANATIONS:

(u).(c) B. Scarlet fever presents with fever, chills, sore throat, and a generalized fine papular rash with a sandpaper texture which begins on the chest. “Strawberry tongue” is also noted

6. In myxedema, the patient commonly complains of which of the following?

A. tremors

B. palpitation

C. cold intolerance

D. eructation

EXPLANATIONS:

(c) C. Myxedema is the result of hypothyroidism. Cold intolerance is associated with hyopthyroidism along with constipation and fatigue.

7. Which of the following signs or symptoms differentiates acute sinusitis from viral rhinitis?

A. fever

B. rhinorrhea

C. facial pain

D. swollen nasal mucous membranes

EXPLANATIONS:

(c) C. Frontal headache, swollen nasal mucous membranes, rhinorrhea and fever may all be signs of viral rhinitis, along with sneezing and a scratchy throat. Sinusitis usually follows a viral rhinitis, but in addition to the above symptoms, it will include pain and tenderness over the involved sinus

8. Which of the following is most commonly seen in viral croup?

A. drooling

B. wheezing

C. sputum production

D. inspiratory stridor

EXPLANATIONS:

9. A patient has double vision when he turns his eyes to the right. Examination shows that he cannot move his right eye laterally. Which of the following cranial nerves is involved?

A. optic

B. oculomotor

C. trochlear

D. abducens

EXPLANATIONS:

10.When palpating a patient’s abdomen at the level of the left costal margin, the physician assistant feels the edge of the spleen. To confirm findings, which of the following is appropriate?

A. Roll the patient onto the right side and palpate for the spleen edge.

B. Roll the patient onto the left side and palpate for the spleen edge.

C. Have the patient get into the knee-chest position.

D. Have the patient sit upright and palpate in the left costal vertebral angle.

EXPLANATIONS:

(c) A. By rolling the patient onto the right side, gravity may bring the spleen forward and medial so that it is in a palpable location.(u) B. See A for explanation.(u) C. By having the patient get into a knee-chest position, fluid would pool into the abdomen by gravity. This is the Puddle’s sign.(u) D. Having the patient sit upright and palpating the left costal vertebral angle would assess for kidneytenderness.REF: (3)

11.Which of the following is a finding in vitamin A deficiency?

A. decreased proprioception

B. night blindness

C. hair loss

D. bleeding

EXPLANATIONS:

(u) A. Decreased proprioception is noted in vitamin E deficiency.(c) B. Night blindness is the earliest symptom of vitamin A deficiency.(u) C. Hair loss is noted in vitamin A toxicity.(u) D. Bleeding is noted in vitamin K deficiency .REF: (16)

12.The physician assistant would suspect food poisoning from

Staphylococcus aureus in a patient who presents with

A. ingestion of mayonnaise-based salads 48 hours earlier.

B. bloody diarrhea with mucus for one week.

C. abdominal cramps and vomiting.

D. high fever

EXPLANATIONS

(u) A. Staphylococcal food poisoning has a short incubation period of 1-8 hours.(u) B. See C for explanation.(c) C. Abdominal cramps, nausea, vomiting, and watery diarrhea typically last 1-2 days withStaphylococcal food poisoning.(u) D. Staphylococcal food poisoning may be associated with low-grade fever or subnormal temperature.REF:

13.The most common location of bleeding seen in patients with von Willebrand’s disease is the

A. mucosal surfaces.

B. spleen.

C. joint spaces.

D. muscle groups.

EXPLANATIONS:

(c) A. Von Willenbrand’s disease most commonly presents with mucosal bleeding such as epistaxis, gingival bleeding, and menorrhagia.(a) B. Splenic bleeding is typically associated with trauma.(u) C. Hemophilia is associated with bleeding into joint spaces, especially knees, ankles, and elbows, and into muscle groups.(u) D. See C for explanation. REF:

14.Which of the following physical findings suggest pernicious anemia?

A. splenomegaly and hepatomegaly

B. petechiae and ecchymosis

C. loss of position and vibratory sensation

D. cheilosis and koilonychia

EXPLANATIONS

(u) A. Splenomegaly and hepatomegaly are typically seen in hemolytic anemias.(u) B. Petechiae and ecchymosis are seen in thrombocytopenia.(c) C. Loss of position and vibratory sensation are common neurologic findings in pernicious anemia.(u) D. Cheilosis and koilonychia are seen in iron deficiency anemi

15. Which of the following is the most common early presenting sign in patients with Alzheimer’s disease?

A. change in personality

B. loss of memory

C. multiple physical complaints

D. depressed mood

EXPLANATIONS:

(u) A. A change in personality is a late finding of Alzheimer’s disease.(c) B. The presence of memory impairment is the most common sign of Alzheimer’s disease. Changes occur first with short-term memory.(u) C. The history of multiple physical complaints is seen most commonly in somatization disorders.(u) D. A depressed mood is the most common presenting feature in depression or dysthymic disorders.

16.The most frequent finding in a person presenting with a brain abscess is

A. nuchal rigidity.

B. headache.

C. seizures.

D. vomiting.

EXPLANATIONS:

(u) A. Nuchal rigidity occurs in approximately 35% of patients with a brain abscess.(c) B. Headache occurs in over 70% of patients with a brain abscess.(u) C. Seizures occur in approximately 35% of patients with a brain abscess.(u) D. Vomiting occurs in approximately 35% of patients with a brain abscess. REF:

17. A 28-year-old female presents on examination with enlarged ovaries bilaterally. The possible diagnosis of polycystic ovarian syndrome is enhanced by finding which of the following?

A. hirsutism

B. gynecomastia

C. anorexia

D. dyspareunia

EXPLANATIONS:

(c) A. The most common findings in polycystic ovarian syndrome are infertility, menstrual irregularities, obesity, and hirsutism. (u) B. See A for explanation.(u) C. See A for explanation.(u) D. See A for explanation. REF: (16)

18.Which of the following signs and symptoms is common in candidal vulvovaginitis?

A. extreme vulvar irritation

B. firm, painless ulcer

C. tender lymphadenopathy

D. purulent discharge

EXPLANATIONS:

(c) A.Candida infection presents with pruritus, vulvovaginal erythema, and white, cheese-like (curd)discharge that is malodorous.(u) B. A firm painless ulcer is seen in syphilis.(u) C. Tender lymphadenopathy is associated with bacterial infections and is not a feature of candidalvulvovaginitis.(u) D. Purulent discharge is noted in gonorrhea.REF: (27)

19. Subacromial bursitis is associated with

A. positive Yergason’s sign.

B. pain along the proximal humeral groove.

C. positive Kanavel’s sign

.D. pain with abduction of the arm from 70-100 degrees.

EXPLANATIONS:

(u) A. Bicipital tendinitis is associated with pain along the proximal humeral groove and a positiveYergason’s sign.(u) B. See A for explanation.(u) C. Kanavel’s sign is associated with flexor tenosynovitis.(c) D. Subacromial bursitis is believed to be part of the continuum of inflammatory conditions affecting the shoulder; initial overuse or trauma involves the rotator cuff, supraspinatus, and bicipital tendons. The inflammation then leads to secondary involvement of the subacromial bursae. Pain and tenderness are localized to the lateral aspect of the shoulder, with signs of impingement on active motion noted on exam between 70-100°abduction.REF: (24)

20. Which of the following physical examination findings is consistent with a herniated disk at L5-S1?

A. hypesthesia of the medial thigh

B. up going Babinski reflex

C. absent Achilles’ reflex

D. decreased sensation in the groin region

EXPLANATIONS:(u) A. Hypesthesia of the medial thigh is consistent with a herniated disk at L3-L4.(u) B. Upgoing Babinski reflex would indicate upper motor neuron disease.(c) C. Depression of the Achilles’ reflex is common with L5-S1disk disease, and may also be present in asignificant number of L4-L5 disk diseases.(u) D. Decreased sensation in the groin region is consistent with a herniated disk at L2-L3.

21.A 65-year-old patient has a long history of schizophrenia that is treated with phenothiazines. On anunrelated clinic visit, the patient has difficulty sticking out her tongue, facial tics, increased blink frequency, and lip-smacking behavior. These involuntary movements are most suggestive of

A. tardive dyskinesia.

B. Parkinson’s disease.

C. Huntington’s disease.

D. Gilles de la Tourette’s syndrome.

EXPLANATIONS:(c) A. Tardive dyskinesia is characterized by abnormal involuntary movements of the face, mouth,tongue, trunk, and limbs and may develop after months or years of treatment with neuroleptic drugs.(u) B. Infrequent blinking, tremor, rigidity, and bradykinesia are characteristic of Parkinsonism.(u) C. Although part of the differential for involuntary movements, this disease has a positive familyhistory and usually appears by age 50.(u) D. Facial motor tics are the most common manifestation of this disorder, but symptoms begin beforeage

21.

REF: (13)

22. 1. HISTORY/PHYSICALTypical symptoms of depression include which of the following?

A. auditory hallucinations

B. panic attacks

C. multiple somatic complaints

D. narcissism

EXPLANATIONS:(u) A. Auditory hallucinations are commonly seen in schizophrenia disorders.(u) B. Panic attacks are noted in anxiety disorders.(c) C. Depressed patients often focus on their bodies and tend to have multiple complaints.(u) D. Narcissism is associated with personality disorders not depression.REF: (16)

23. 1. HISTORY/PHYSICALA 47-year-old patient with Type 1 diabetes presents in a coma due to diabetic ketoacidosis. He is noted to have rapid deep breathing. Which of the following best describes this patient’s breathing pattern?

A. ataxic breathing

B. Cheyne-Stokes breathing

C. Kussmaul breathing

D. obstructive breathing

EXPLANATIONS:(u) A. Biot’s breathing, also known as ataxic breathing, is characterized by unpredictable irregularity.(u) B. Cheyne-Stokes breathing is characterized by periods of deep breathing alternating with periods of apnea. This is caused by heart failure, uremia, drug-induced respiratory depression, and brain damage.(c) C. Kussmaul breathing is deep breathing, and in this case, is a compensatory mechanism formetabolic acidosis.(u) D. Obstructive breathing is seen in patients with COPD.REF: (3)

c = Correct u = Unsatisfactorya = Acceptable h = Potentially harmful

24. 1. HISTORY/PHYSICALParadoxical motion of the chest wall occurs in which of the following?

A. barrel chest

B. flail chest

C. funnel chest

D. pigeon chest

EXPLANATIONS:(u) A. A barrel chest has an increased anteroposterior diameter.(c) B. If multiple ribs are fractured in multiple places, paradoxical movements of the thorax may be seen. As descent of the diaphragm decreases intrathoracic pressure on inspiration, the injured area caves inward. On expiration, it moves outward.(u) C. A funnel chest is characterized by a depression in the lower portion of the sternum. Compressionof the heart and great vessels may cause murmurs.(u) D. In a pigeon chest, the sternum is displaced anteriorly, increasing the anteroposterior diameter.The costal cartilages adjacent to the protruding sternum are depressed.REF: (3)

25. 1. HISTORY/PHYSICALA 49-year-old male presents with complaints consistent with Peyronie’s disease. Which of the following is the most likely physical examination finding in this patient?

A. inflammation of the glands of the penis

B. foreskin that cannot be retracted

C. chancre on the shaft of the penis

D. fibrous band on lateral portion of the penis

EXPLANATIONS:(u) A. Inflammation of the glands of the penis is noted in balanitis.(u) B. A foreskin that cannot be retracted is seen in phimosis.(u) C. A chancre on the shaft of the penis is noted in primary syphilis.(c) D. Peyronie disease typically presents with fibrotic areas under the penile skin along with a history ofpenile curvature during erection.REF: (3)

26.Renal cell carcinoma most commonly presents with which of the following symptoms or signs?

A. hypocalcemia

B. inguinal pain

C. anemia

D. hematuria

EXPLANATIONS:(u) A. Renal cell cancer may present with hypercalcemia.(u) B. See D for explanation.(u) C. Renal cell cancer may present with polycythemia, not anemia.(c) D. The most common presenting symptom/sign of renal cell carcinoma is hematuria (approximately60%). Flank pain or abdominal mass is present in about 30% of new cases.

c = Correct u = Unsatisfactorya = Acceptable h = Potentially harmful

27. Which of the following is the diagnostic test of choice for the evaluation of a patient suspected of secondary hypertension due to primary aldosteronism (Conn’s syndrome)?

A. chest x-ray

B. renal scan

C. serum electrolytes

D. urinalysis for metanephrines

EXPLANATIONS:(u) A. Chest x-ray may be used to evaluate a patient suspected of having coarctation of the aorta as acause of secondary hypertension.(u) B. A renal scan is indicated in the evaluation of a patient suspected of having secondary hypertension due to renal artery stenosis or fibromuscular dysplasia of the renal arteries.(c) C. Patients having primary aldosteronism as a cause of their secondary hypertension are identified forthis condition by finding unprovoked hypokalemia on the electrolyte testing.(u) D. Patients having secondary hypertension due to pheochromocytoma will have an increase in theirurinary metanephrines on testing due to increased catecholamine production by this tumor.REF: (9)

28. Which of the following electrocardiographic findings is the hallmark of pericarditis?

A. ST elevation

B. prolonged Q-T interval

C. atrial fibrillation

D. tall peaked T waves

EXPLANATIONS:(c) A. The hallmark of pericarditis is ST segment elevation throughout the precordium along with PRsegment depression.(u) B. Prolonged Q-T interval is typically the result of hypocalcemia or due to the use of medications.(u) C. Pericarditis is not related to the production of atrial fibrillation.(u) D. Tall peaked T waves are classically associated with hyperkalemia.REF: (9)

29. Patients with heart failure may have a combination of systolic and diastolic failure. Which of the following studies should be used in diagnosing this condition?

A. radionuclide scanning

B. echocardiogram

C. exercise stress testing

D. cardiac catheterization

EXPLANATIONS:(u) A. Radionuclide scanning is primarily used for the evaluation of coronary artery disease as it is able toassess areas of perfusion for the heart.

(c) B. An echocardiogram is especially useful for assessing the dimensions of each cardiac chamber.Heart failure is usually associated with cardiac enlargement and the diagnosis should be questioned (but,not excluded) when all chambers are normal in size. Echocardiogram assesses the function of thevarious chambers along with the ejection fractions of the heart, which is important with systolic dysfunction. C. Exercise stress testing is primarily used to assess a patient’s cardiovascular status in response to exercise and is primarily a strategy involved in assessing patients for coronary artery disease, not congestive or chronic heart failure.(u) D. Cardiac catheterization has no role in the evaluation of a patient with CHF. It is used to assess the amount of coronary artery disease in a patient for whom revascularization surgery is being contemplated.REF: (9)

30. 2. DIAG STUDIES The most accurate method of diagnosing thrombophlebitis of the lower leg is

A. impedance plethysmography.

B. physical exam findings.

C. Doppler ultrasound.

D. venography

.EXPLANATION:(u) A. See D for explanation.(u) B. See D for explanation.(u) C. See D for explanation.(c) D. While impedance plethysmography, physical exam findings, and Doppler ultrasound are useful indiagnosing thrombophlebitis, venography is the most accurate method for diagnosis in the lower leg.REF: (9)

31. The serum creatine phosphokinase-mB (CPK-MB) rises to a peak after an acute myocardial infarctionafter how many hours?

A. 4 – 6

B. 8 – 12

C. 18 – 20

D. 48 – 72

EXPLANATIONS:(u) A. See C for explanation.(u) B. See C for explanation.(c) C. CPK-MB is found mainly in cardiac muscle. It begins to rise in 4 to 6 hours, peaks at 18 hours, and returns to normal in 48 hours.(u) D. See C for explanation.REF: (9)

32. Which of the following enzymes is most specific for injury or death of the heart muscle?

A. troponin-I

B. serum aldolase

C. myoglobin

D. alanine aminotransferase

EXPLANATIONS

(c) A. Troponin-I is a regulatory protein in the troponin cardiac muscle complex. It is specific formyocardium and is elevated in injury or death of the heart muscle.(u) B. Serum aldolase is elevated in skeletal muscle disorders, such as muscular dystrophies.

. (u) C. While myoglobin is elevated in heart muscle injury or death it is not specific.(u) D. Alanine aminotransferase is predominantly found in the liver and is elevated in disorders causingliver cell injury.REF: (9)

33.A 24-year-old male presents with a generalized erythematous maculopapular rash, including the palmsand soles of the feet. He also shows generalized lymphadenopathy and flat, moist lesions in the genitalarea. The patient admits to having had a lesion on his penis a month or so before, but it did not botherhim. Which of the following is the most appropriate to confirm the diagnosis?

A. C-reactive protein

B. Lyme titer

C. FTA-ABS

D. Weil-Felix test

EXPLANATIONS:

(u) A. C-reactive protein is nonspecific for inflammatory processes.(u) B. Lyme titer is elevated in Lyme’s disease.(c) C. The fluorescent treponemal antibody absorption test is positive in secondary syphilis.(u) D. The Weil-Felix test is positive in cases of rickettsial diseases.REF: (9)

34.A 55-year-old female presents with a mole that has changed appearance over the past few months. Shesays it has enlarged. Also noted is an asymmetric lesion with an irregular border and variation in colorfrom light brown to dark blue/black. Which of the following is the most appropriate?

A. curettage

B. shave biopsy

C. excisional biopsy

D. aspiration for cytology

EXPLANATIONS:(h) A. Curettage and shave biopsy are contraindicated for suspected melanoma because they leavebehind potentially cancerous cells.(h) B. See A for explanation.(c) C. An excisional biopsy is indicated for suspected cases of melanoma.(u) D. See C for explanation

35.Which of the following is the most helpful in establishing the diagnosis of gout?

A. analysis of synovial fluid with polarized light

B. C-reactive protein

C. erythrocyte sedimentation rate

D. serum and urine uric acid

EXPLANATIONS:(c) A. Although sedimentation rate, C-reactive protein, and uric acid levels may be elevated, the mostspecific diagnostic test for gout is the presence of negatively birefringent, needlelike crystals in leukocytesfrom synovial fluid.(u) B. See A for explanation.(u) C. See A for explanation.(u) D. See A for explanation.REF: (7A

36.24-year-old male is initially found to have a single nodule in the right lobe of his thyroid gland. He isclinically and chemically euthyroid. The next step is to

A. reassure the patient and reassess yearly.

B. recheck in 1-3 months.

C. do a fine needle aspiration.

D. obtain a CT scan of the neck.

EXPLANATIONS:(h) A. See C for explanation.(h) B. See C for explanation.(c) C. The combination of fine needle aspiration and radioisotope scanning of a solitary thyroid nodule provides the best diagnostic yield. Because cold nodules may be cancerous, they are generally referred for surgical removal. It is not reasonable to delay the diagnosis.(u) D. Ultrasound is preferred over MRI or CT scan of the thyroid.REF: (7)

37. In differentiating a viral pharyngitis from a streptococcal pharyngitis, which of the following must be included?

A. complete blood count with differential

B. ASO titer

C. cold agglutinin antibody test

D. throat culture

EXPLANATIONS:

(u) A. CBC is too nonspecific to differentiate between the conditions.(u) B. ASO titers are used to identify past infections with strep, not current infections, as the titerincreases in the convalescent phase.(u) C. Cold agglutinins are nonspecific and are positive in mycoplasma pneumonia, influenza,mononucleosis, and rheumatoid arthritis.(c) D. The throat culture is the definitive test to identify beta-hemolytic Group A streptococci.REF: (9)

38.A 2-year-old presents with sudden onset of cough and stridor. On examination the child is afebrile andappears well with a respiratory rate of 42 per minute. What is the next best step in the evaluation andtreatment of this patient?

A. lateral soft tissue x-ray of the neck

B. indirect laryngoscopy

C. thoracocentesis

D. barium swallow

EXPLANATIONS:(u) A. While lateral x-ray of the soft tissues of the neck may be done only 7% of all aspirated foreignbodies are radiopaque. Lateral x-ray is typically done for epiglottitis and retropharyngeal abscess.(c) B. Laryngoscopy is indicated not only for diagnosis, but also removal of the foreign body.(u) C. Thoracocentesis is not indicated in patients with airway foreign body aspiration.(u) D. Barium swallow is used to evaluate for possible esophageal foreign body aspiration. Wheezing and stridor are not common.

39. A 24-year-old male presents with complaints of increasing drainage from both eyes associated with mild discomfort for the past day. He denies severe or deep eye pain and any blurring of his vision. On examination, his visual activity is 20/20 OU. There is moderate erythema and edema of the eye lids diffuse conjunctival injection, and profuse thick mucopurulent discharge on the conjunctiva and lids.Which of the following is the most appropriate diagnostic evaluation?

A. culture

B. Giemsa stain

C. Tzanck smear

D. direct fluorescent antibody testing

EXPLANATIONS:

(c) A. This is the typical presentation of a bacterial conjunctivitis. Due to the severity of the presentationand possibility of infection caused byNeisseria gonorrheae initial evaluation by Gram stain and cultureshould be performed.(u) B. Giemsa stain and direct fluorescent antibody testing are both indicated for evaluation of possible infection caused by Chlamydia trachomatis

.(u) C. Tzanck smear is indicated for evaluation of possible infection caused by herpes simplex viruses.(u) D. See B for explanation.REF: (16)

40.A 4-year-old patient presents with increasing redness and swelling involving her right eye for the past 2days. The mother states that the child has become increasingly irritable, less active, and appears tohave an increased temperature. The child had a recent “cold” and nasal congestion prior to onset ofthese symptoms. Examination reveals an ill-appearing 4-year-old child lying quietly on the exam table.Temperature is 102°F. Visual activity is 20/40 in the right eye and 20/30 in the left eye. The right eyereveals mild proptosis and severe erythema, increased warmth, and swelling involving the eye andsurrounding tissues. Which of the following is the most appropriate diagnostic evaluation?

A. applanation tonometry

B. electronystagmography

C. orbital and sinus CT scan

D. ultrasonography of sinuses

EXPLANATIONS:

(u) A. Applanation tonometry is utilized in the measurement of intraocular pressure with suspectedglaucoma and is, therefore, not indicated in this patient.(u) B. Electronystagmography is an objective recording of induced nystagmus utilized for the evaluationof vertigo and is not indicated in this patient.(c) C. This is the typical presentation of orbital cellulitis. A CT scan of the orbit and sinuses is indicatedto check for the presence of a subperiosteal abscess and underlying sinusitis, which is often the cause oforbital cellulitis.(u) D. Ultrasonography of the sinuses is not clinically utilized to evaluate for the presence of sinusitis ororbital cellulitis.REF: (24)

41. 2. DIAG STUDIESA 65-year-old patient with a known history of alcohol and tobacco abuse presents with solid-fooddysphagia. The patient also had a 24 lb weight loss over the past 6 months. To establish a diagnosis,which of the following studies should be performed?

A. CT scan

B. chest x-ray

C. barium esophagram

D. endoscopy

EXPLANATIONS:

(u) A. CT scan should be obtained once the diagnosis of carcinoma has been made to evaluate forpulmonary or hepatic metastases, lymphadenopathy, and local tumor extension.(u) B. Chest x-ray may show adenopathy, a widened mediastinum, pulmonary or bony metastases, orsign of tracheoesophageal fistula such as pneumonia.(u) C. Barium esophagram is obtained as the first study to evaluate the dysphagia.(c) D. Endoscopy with biopsy establishes the diagnosis of esophageal carcinoma with a high degree ofreliability when biopsy is included as part of the procedure.REF: (16)

c = Correct u = Unsatisfactorya = Acceptable h = Potentially harmful

42. 2. DIAG STUDIESA 35-year-old male presents to the emergency department with a 4-hour history of abdominal pain nausea, and vomiting. He denies diarrhea. Examination reveals the following: Temperature 101°F (38.3°C) Pulse 100 beats/minRespiratory rate 20/minBlood pressure 110/65 mm HgThe patient is in moderate distress and slightly diaphoretic. He has poor oral hygiene and the odor ofalcohol is noted. Examination of the heart and lungs are unremarkable except for tachycardia.Abdominal examination reveals hypoactive bowel sounds, diffuse tenderness with more markedtenderness in the epigastric area, without guarding, rebound, masses, or organomegaly. Along withCBC, which of the following diagnostic studies would be most appropriate?

A. liver function tests, amylase, and abdominal films

B. ESR, urinalysis, and electrolytes

C. electrolytes, ECG, and upper GI

D. ECG, barium enema, and sonogram

EXPLANATIONS

(c) A. The clinical presentation suggests acute pancreatitis, which is best evaluated by liver functiontests, amylase, and abdominal films.(u) B. ESR is for nonspecific indication of inflammation. Urinalysis may be useful for evaluating fluidstatus (specific gravity) or urinary system involvement only. Electrolytes may be useful in prolongedvomiting. These tests do not help in the diagnosis of any specific entities that may cause epigastric pain.While an ECG may be indicated in patients with epigastric pain, an upper GI is not a first-line diagnostictest.(u) C. See B for explanation.(u) D. Given the clinical presentation, a sonogram and barium enema are not indicated.REF: (9)

43. 2. DIAG STUDIESWhich of the following is the most helpful serological test in primary biliary cirrhosis?

A. anti-smooth muscle antibodies

B. anti-mitochondrial antibodies

C. anti-hepatitis B antibodies

D. anti-nuclear antibodies

EXPLANATIONS:(u) A. Anti-smooth muscle antibodies are commonly seen in autoimmune hepatitis.(c) B. Anti-mitochondrial antibodies are seen in over 90% of cases of primary biliary cirrhosis and arerare in other forms of liver disease.(u) C. Anti-hepatitis B antibodies are commonly seen in viral hepatitis B.(u) D. Anti-nuclear antibodies are commonly seen in rheumatoid arthritis, lupus, scleroderma, and Sjogren syndrome.REF: (9)

c = Correct u = Unsatisfactory a = Acceptable h = Potentially harmful

44. 2. DIAG STUDIESA 26-year-old male patient presents with complaints of diarrhea with marked flatulence and weight loss for the past 6-8 months. In addition, he states that his stools are loose and soft with an oily appearance and foul smelling. The patient has not traveled out of the country. Which of the following laboratory tests would be most helpful based upon this history?

A. stool for leukocytes

B. stool for ova and parasites

C. stool for 72-hour fecal fat

D. stool for culture and sensitivity

EXPLANATIONS:(u) A. See B for explanation.(u) B. Laboratory tests stool for culture and sensitivity, leukocytes and ova and parasites would bewarranted if the patient had evidence of bacterial or parasitic infection.(c) C. Steatorrhea is usually present, but may be absent in mild disease of celiac sprue. A quantitative72-hour stool collection taken while patients are consuming a 100 gm fat diet is a more sensitive meansof detecting fat malabsorption.(u) D. See B for explanation.REF: (16)

45. 2. DIAG STUDIESThe physician assistant is evaluating a patient suspected of having an irondeficiency anemia. When examining the patient’s peripheral blood smear, thediagnosis is reinforced by noting

A. shistocytes.

B. Howell-Jolly bodies.

C. macrocytic red blood cells.

D. hypochromic, microcytic red blood cells

EXPLANATIONS:

(u) A. Shistocytes are typically noted in hemolytic anemias.(u) B. Howell-Jolly bodies are noted in patients who have had the spleen removed or have a non-functioning spleen.(u) C. Macrocytic red blood cells are noted in megaloblastic anemias, not iron deficiency anemia.(c) D. Hypochromic, microcytic red blood cells are common in patients with iron deficiency anemia.REF: (9)

c = Correct u = Unsatisfactorya = Acceptable h = Potentially harmful

46. 2. DIAG STUDIES An 18-year-old patient presents with fever, pharyngitis, and cervical lymphadenopathy. The CBC shows a leukocytosis with 25% atypical lymphocytes. Which of the following is the diagnostic test of choice for this patient?

A. heterophile test

B. throat culture

C. blood culture

D. lymph node biopsy

EXPLANATIONS:(c) A. A heterophile test is the test of choice for the diagnosis of infectious mononucleosis.(u) B. Throat culture is used in the diagnosis of strep pharyngitis. Strep pharyngitis does not present withatypical lymphocytes.(u) C. Blood cultures are of no value in the diagnosis of infectious mononucleosis.(u) D. A lymph node biopsy is used in the diagnosis of lymphoma. Lymphoma typically does not presentwith pharyngitis or atypical lymphocytes.REF: (9)

47. 2. DIAG STUDIESWhich of the following would aid in the diagnosis of Reye’s syndrome?

A. hyperglycemia

B. elevated serum ammonia level

C. proteinuria

D. elevated cholesterol

EXPLANATIONS:(u) A. Hypoglycemia is more likely to be seen in Reye’s syndrome.(c) B. Reye’s syndrome results in fatty liver with encephalopathy. It is a complication of influenza andother viral illnesses, particularly in the young and with the use of aspirin. Laboratory characteristicsinclude elevated ammonia levels, elevation of liver enzymes, hypoglycemia, and a prolonged prothrombintime.(u) C. Reye’s syndrome does not affect the kidneys and should not result in proteinuria.(u) D. Cholesterol should not be affected by Reye’s syndrome.REF: (16)

c = Correct u = Unsatisfactorya = Acceptable h = Potentially harmful

48. 2. DIAG STUDIES Which of the following laboratory studies may be used in the prenatal diagnosis of spina bifida?

A. hCG

B. alpha-fetoprotein

C. folic acid levels

D. prolactin

EXPLANATIONS:(u) A. HCG is used to assess Down’s Syndrome as part of the maternal triple screen.(c) B. Alpha-fetoprotein, measured at 16-18 weeks of pregnancy, if elevated, would indicate a neural tube defect, such as spina bifida.(u) C. Folic acid has been shown to decrease the incidence of neural tube defects, not as an aid in diagnosis of the defect.(u) D. Prolactin is a hormone with the main purpose of inducing lactation. It would have no value in thediagnosis of spina bifida.REF: (27)

49. 2. DIAG STUDIESIn suspected subarachnoid hemorrhage with a negative head CT, which of the following studies shouldbe used to help establish the diagnosis of subarachnoid hemorrhage?

A. complete blood count

B. lipid profile

C. lumbar puncture

D. electrocardiogram

EXPLANATIONS:(u) A. A complete blood count has no diagnostic value in the evaluation of a subarachnoid hemorrhage.(u) B. A lipid profile may reveal elevated cholesterol and triglycerides, and risk factors for intracerebralhemorrhages, but it is of no diagnostic value.(c). C. Although 95% of subarachnoid hemorrhages show blood on head CT, the remaining do not showevidence of hemorrhaging. A lumbar puncture should then be performed and the fluid examined for redblood cells or xanthochromia.(u) D. An electrocardiogram may show diffuse T wave inversion in the precordial leads in a subarachnoidhemorrhage, but these are not always present.REF: (9)

c = Correct u = Unsatisfactorya = Acceptable h = Potentially harmful

50. 2. DIAG STUDIESWhich of the following is the best test to confirm the presence of gonorrhea in a female?

A. culture of the endocervix

B. culture of vaginal discharge

C. Gram stain of cervical discharge

D. presence of yellow discharge

EXPLANATIONS:(c) A. The standard for diagnosis of gonorrhea is the isolation of the organism by culture from theendocervix in women.(u) B. See A for explanation.(u) C. Gram stain can be done on urethral and endocervical exudates to warrant a presumptivediagnosis.(u) D. See A for explanation.REF: (9)

51. 2. DIAG STUDIESWhich of the following is the primary technique for evaluation of an abnormal cervical cytology smear?

A. laparoscopy

B. colposcopy

C. abdominal CT scan

D. dilation and curettage

EXPLANATIONS:(u) A. Laparoscopy is used to evaluate pelvic structure, not for evaluation of abnormal cervical cytologysmear.(c) B. Colposcopy is the primary method for evaluation of abnormal cervical cytology smear.(u) C. Abdominal CT scan is used to evaluate pelvic structures.(u) D. Dilation and curettage is used to evaluate abnormal uterine bleeding.REF: (27)

52. 2. DIAG STUDIESWhich of the following is a common x-ray finding seen in osteoarthritis?

A. osteophyte formation

B. chondrocalcinosis

C. fat pad displacement

D. moth-eaten bone destruction

EXPLANATIONS:(c) A. Osteophyte formation and joint space narrowing are common in osteoarthritis.(u) B. Chondrocalcinosis is seen in pseudogout.(u) C. Fat pad displacement is a soft tissue change noted in fractures of the wrist and elbow.(u) D. Moth-eaten bone destruction is noted in osteomyelitis and certain bone cancers.REF: (9)

c = Correct u = Unsatisfactorya = Acceptable h = Potentially harmful

53. 2. DIAG STUDIESA break in the cortex of one side of the bony shaft without a separation or break of the opposite cortex is called what type of fracture?

A. greenstick

B. transverse

C. torus

D. epiphyseal

EXPLANATIONS:(c) A. A greenstick fracture is a break in the cortex of one side of bone shaft without a break in theopposite cortex.(u) B. A transverse fracture is a complete fracture of both cortices.(u) C. A torus fracture is a bowing, bending, or buckling without a break in the cortex.(u) D. Epiphyseal fracture occurs at the growth plate. REF: (24)

54. 2. DIAG STUDIES Which of the following abnormalities is most commonly noted in bulimia nervosa?

A. metabolic acidosis

B. hypokalemia

C. hyperalbuminemia

D. amenorrhea

EXPLANATIONS:(u) A. A metabolic alkalosis may be noted if potassium losses from purging are great enough.(c) B. Episodes of binge eating are followed by purging in the bulimic patient. Vomiting and laxative abuse are the most common methods of purging, leading to hypokalemia.(u) C. Serum albumin levels may be normal or decreased.(u) D. Unlike anorexia nervosa, a patient who is bulimic may maintain a normal body weight and normal menstruation.REF: (13)

55. 2. DIAG STUDIES Which of the following laboratory tests is most appropriate to perform on a patient taking clozapine(Clozaril)?

A. BUN and creatinine

B. white blood cell count

C. liver function tests

D. brain EEG

EXPLANATIONS:(u) A. See B for explanation.(c) B. Agranulocytosis is a known complication of clozapine and weekly complete blood counts aremandatory when this medication isgiven.(u) C. See B for explanation.(u) D. See B for explanation.REF: (14)

c = Correct u = Unsatisfactorya = Acceptable h = Potentially harmful

56. 2. DIAG STUDIESWhich of the following is the most common radiographic presentation of pulmonary tuberculosis?

A. cavitation

B. pleural thickening

C. hilar mass

D. hyperinflation

EXPLANATIONS:(c) A. Cavitation is seen with progressive primary tuberculosis or lung abscess.(u) B. Pleural thickening is noted in mesothelioma.(u) C. Hilar and mediastinal abnormalities are common on chest radiography in patients with lung cancer.(u) D. Hyperinflation is the main clinical feature in emphysema.REF: (9)

57. 2. DIAG STUDIESA 72-year-old patient with a long standing history of COPD will have a reduction in which of the followingon spirometry?

A. forced vital capacity (FVC)

B. total lung capacity (TLC)

C. residual volume (RV)D. RV/TLC ratio

EXPLANATIONS:(c) A. In severe COPD, the forced vital capacity is markedly reduced. Lung volume measurementsreveal an increase in total lung capacity, a marked increase in residual volume, and an elevation of theRV/TLC ratio,is indicative of air trapping, particularly in emphysema.(u) B. See A for explanation.(u) C. See A for explanation.(u) D. See A for explanation.REF: (16)

58. 2. DIAG STUDIESA 68-year-old patient with chronic obstructive pulmonary disease will typically demonstrate a decreased

A. serum bicarbonate content.

B. blood hemoglobin.

C. blood pCO2.

D. blood pH

.EXPLANATIONS:

(u) A. The serum bicarbonate content is sometimes normal, but is usually increased in respiratoryacidosis.(u) B. An elevated, not decreased, hemoglobin can be seen in heavy smokers, which is the primarycause of emphysema.(u) C. COPD causes CO2retention, which would result in an increased, not decreased, pCO2.(c) D. COPD causes a state of respiratory acidosis, which would account for the decreased blood pH.REF: (16)

c = Correct u = Unsatisfactorya = Acceptable h = Potentially harmful

59. 2. DIAG STUDIESThe diagnostic gold standard to rule out pulmonary embolism is

A. chest x-ray.

B. spiral CT scan.

C. ventilation/perfusion scan.

D. pulmonary angiography.

EXPLANATIONS:(u) A. See D for explanation.(u) B. See D for explanation.(u) C. See D for explanation.(c) D. Although chest x-ray, arterial blood gases, and ventilation-perfusion scans may be obtained in thework-up of suspected pulmonary embolism, the arteriogram remains the “gold standard” for diagnosis.REF: (9)

60. 2. DIAG STUDIESA urinalysis performed during a routine physical examination on a 43-year-old male reveals 1-2 hyaline casts/HPF. The remainder of the UA is normal. Based upon these results, the physician assistant should

A. collect a urine for culture and sensitivity.

B. do nothing, since these casts are considered normal.

C. refer the patient to a nephrologist.

D. schedule the patient for a CT scan.

EXPLANATIONS:(u) A. See B for explanation.(c) B. Hyaline casts are not indicative of renal disease. They can be found following strenuous exerciseand with concentrated urine or during a febrile illness.(u) C. See B for explanation.(u) D. See B for explanation.REF: (16)

61. 2. DIAG STUDIESWhich of the following urine findings is pathognomonic for acute pyelonephritis?

A. red blood cell casts

B. hyaline casts

C. leukocyte casts

D. renal tubular epithelial casts

EXPLANATIONS:(u) A. Red blood cell casts are seen in glomerular disease.(u) B. Hyaline casts may be seen in normal urine.(c) C. White blood cell casts are pathognomonic for acute pyelonephritis.(u) D. Renal tubular epithelial cell casts are associated with ischemic and nephrotoxic acute renal failure.REF: (9)

c = Correct u = Unsatisfactorya = Acceptable h = Potentially harmful

62. 2. DIAG STUDIESIn renal insufficiency, which of the following is used to assess glomerular filtration rate (GFR)?

A. urinalysis

B. blood urea nitrogen

C. renal plasma flow measure

D. creatinine clearance

EXPLANATIONS:(u) A. See D for explanation.(u) B. See D for explanation.(u) C. See D for explanation.(c) D. The GFR provides an overall index of renal function. Creatinine is normally cleared by renalexcretion; as renal GFR declines, serum creatinine will increase.REF: (16)

63. 3. DIAGNOSISA 59-year-old male complains of pain in his right leg for the last few months. He is normally able to walktwo miles a day, but has noted pain when he climbs hills, which is relieved with rest or resuming walkingon flat ground. He also complains of foot pain at rest. He does not smoke and denies injury to his back.He has been generally healthy with obesity and mildly elevated triglycerides. The most likely cause ofthe pain in this patient is

A. sciatica.

B. diabetic neuropathy.

C. deep vein thrombosis

D. intermittent claudication.

EXPLANATIONS:(u) A. See D for explanation.(u) B. See D for explanation.(u) C. Deep vein thrombosis does not cause intermittent pain, but rather continuous aching pain not relieved by rest.(c) D. Symptoms of intermittent claudication and arterial occlusive disease include pain with exercise that is relieved by rest; pain in the feet at rest indicates severe circulatory compromise. The history of obesity and elevated triglycerides is consistent with peripheral vascular disease. Although this patient could also be at risk for diabetes, the most likely immediate problem is vascular in nature.REF: (9)

c = Correct u = Unsatisfactorya = Acceptable h = Potentially harmful

64. 3. DIAGNOSISA 46-year-old female is being evaluated for a new-onset hypertension that was discovered on screeningat her workplace. The patient had several readings revealing systolic and diastolic hypertension.Physical examination is normal. A complete laboratory evaluation was performed with unexplainedhypokalemia as the only abnormality found. Which of the following is the most likely diagnosis for thispatient?

A. pheochromocytoma

B. renal artery stenosis

C. coarctation of the aorta

D. primary aldosteronism

EXPLANATIONS:

(u) A. Pheochromocytoma will result in an increase in the production and release of catecholamines,which results in an increase in urinary metanephrines on testing.(u) B. Renal artery stenosis is identified by an abnormal radionuclide uptake on the affected kidney.(u) C. Coarctation of the aorta is identified by delayed and weakened femoral pulses along with a blood pressure in the lower extremities significantly lower than in the upper extremities.(c) D. Primary aldosteronism has an increased aldosterone secretion, which causes the retention of sodium and the loss of potassium. This should be the primary consideration for this patient.REF: (9)

65. 3. DIAGNOSIS An 8-year-old boy is brought to a physician because of palpitation, fatigue, and dyspnea. On examination, a continuous machinery murmur is heard best in the second left intercostal space and is widely transmitted over the precordium. The most likely diagnosis is

A. ventricular septal defect.

B. atrial septal defect.

C. congenital aortic stenosis.

D. patent ductus arteriosus.

EXPLANATIONS:

(u) A. VSD causes a holosystolic murmur rather than a continuous machinery-like murmur.(u) B. ASD causes a fixed split S2 rather than a continuous systolic heart murmur.(u) C. Congenital aortic stenosis causes a crescendo-decrescendo systolic murmur heard best in thesecond intercostal space.(c) D. Patent ductus arteriosus is classically described in children as a continuous machinery-typemurmur that is widely transmitted across the precordium.REF: (9)

c = Correct u = Unsatisfactorya = Acceptable h = Potentially harmful

66. 3. DIAGNOSISA patient who appears very anxious enters the office complaining of dizziness with perioral and extremity paresthesias. She vaguely describes some chest discomfort. Physical examination is unremarkable, except for moderate tachypnea with obvious sighing respiration. This clinical picture is most consistent with

A. bronchial asthma.

B. hyperventilation syndrome.

C. spontaneous pneumothorax.

D. anaerobial emphysema.

EXPLANATIONS:

(u) A. Bronchial asthma attacks are associated with increased dyspnea and prolonged expiration. Patients may use accessory muscles of respiration as part of this acute condition.(c) B. Anxiety may result in hyperventilation that can result in perioral numbness and paresthesias of the extremities. These paresthesias are due to decreased CO2in the blood stream that results from the hyperventilation. Anxious patients also will have nondescript chest pain as part of this condition and mayalso complain of dizziness.(u) C. Spontaneous pneumothorax patients will primarily complain of significant chest pain along with their dyspnea. These patients will not have perioral or extremity paresthesias. (u) D. Emphysema alone will not result in hyperventilation or the production of perioral or extremity paresthesias and is a chronic progressive rather than an acute onset condition.REF: (9)

67. 3. DIAGNOSISA 12-year-old boy presents to the office with pain in his legs with activity gradually becoming worse over the past month. He is unable to ride a bicycle with his friends due to the pain in his legs. Examination of the heart reveals an ejection click and accentuation of the second heart sound. Femoral pulses are weak and delayed compared to the brachial pulses. Blood pressure obtained in both arms is elevated. Chest x-ray reveals rib notching. Which of the following is the most likely diagnosis?

A. abdominal aortic aneurysm

B. pheochromocytoma

C. coarctation of the aorta

D. thoracic outlet syndrome

EXPLANATIONS:

(u) A. Abdominal aortic aneurysm is usually asymptomatic until the patient has dissection or rupture. It isuncommon in a child.(u) B. Pheochromocytoma classically causes paroxysms of hypertension due to catecholamine releasefrom the adrenal medulla, but does not cause variations in blood pressure in the upper and lowerextremities.(c) C. Coarctation is a discrete or long segment of narrowing adjacent to the left subclavian artery. As a result of the coarctation, systemic collaterals develop. X-ray findings occur from the dilated and pulsatile intercostal arteries and the “3”is due to the coarctation site with proximal and distal dilations.(u) D. Thoracic outlet syndrome occurs when the brachial plexus, subclavian artery, or subclavian vein becomes compressed in the region of the thoracic outlet. It is the most common cause of acute arterial occlusion in the upper extremity of adults under 40 years old. REF: (5)

c = Correct u = Unsatisfactory a = Acceptable h = Potentially harmful

68. 3. DIAGNOSISA 55-year-old morbidly obese male is seen in the office for routine examination. He has a history of pulmonary hypertension and cor pulmonale. Examination reveals a palpable jugular venous pulse alongwith a systolic flow murmur on the right side of the sternum. Which of the following is the most likelydiagnosis?

A. mitral insufficiency

B. tricuspid insufficiency

C. hepatic vein thrombosis

D. aneurysm of the thoracic aorta

EXPLANATIONS:(u) A. Mitral insufficiency results in the accumulation of blood primarily in the pulmonary system and notthe right side of the heart.(c) B. Tricuspid insufficiency will result in blood being put back into the right side of the body withincreased jugular pulsation in the neck, along with a palpable venous pulse in the liver.(u) C. Hepatic vein thrombosis or Budd-Chiari syndrome is associated with cirrhosis and liver clottingabnormalities and is not due to right-sided heart failure.(u) D. Thoracic aorta aneurysm results in a widened mediastinum that is fairly asymptomatic until itresults in rupture or dissection. These are typically found as incidental findings unless they aresymptomatic from dissection or rupture, which causes severe chest pain or a severe tearing sensation inthe chest.REF: (9)

69. 3. DIAGNOSISOn a routine neonate examination, a grade IV/VI holosystolic murmur is heard in the 3rd-4th leftintercostal space in the parasternal line. The murmur is most likely that of

A. atrial septal defect.

B. ventricular septal defect.

C. patent ductus arteriosus.

D. mitral stenosis.

EXPLANATIONS:

(u) A. Atrial septal defect will cause fixed splitting of the S2 heart sound as its dramatic auscultatoryfinding.(c) B. Ventricular septal defect does cause a holosystolic murmur with blood flowing primarily from theleft to the right side during systole.(u) C. Patent ductus arteriosus causes a continuous machinery-like murmur from blood flowing throughthis structure that failed to close after birth.(u) D. Mitral stenosis causes an opening snap and is a diastolic, not systolic, heart murmur.REF: (9)

c = Correct u = Unsatisfactorya = Acceptable h = Potentially harmful

70. 3. DIAGNOSISA patient presents complaining of dyspnea with exercise that worsen at night. He has to use threepillows to sleep comfortably. The most likely diagnosis is which of the following?

A. pneumonia

B. mitral valve disease

C. chronic heart failure

D. atelectasis

EXPLANATIONS:(u) A. Pneumonia may be related to episodic dyspnea related to coughing, but it does not classicallycause orthopnea.(u) B. Mitral valve disease may cause exertional dyspnea as one of the early symptoms from bloodbacking up into the pulmonary system, but it does not primarily cause orthopnea unless this is related tochronic heart failure.(c) C. Congestive or chronic heart failure is associated with orthopnea and even paroxysmal nocturnaldyspnea because of increased venous return of blood to the heart when the patient assumes a supineposition.(u) D. Atelectasis results from a portion of the lung collapsing, usually due to patients not taking a deepbreath. This condition is primarily seen in post-operative patients who have pain that makes deepbreathing difficult.REF: (16)

71. 3. DIAGNOSISA 65-year-old male presents to the emergency department with chest pain since yesterday. The patientdescribes the pain as severe with tingling, but denies dyspnea. On examination, there is a tender bandof erythema with superimposed vesicles and bullae on the left anterior chest wall, extending from the leftside of the sternum laterally. Which of the following is the most likely diagnosis?

A. bullous pemphigoid

B. contact dermatitis

C. pityriasis rosea

D. herpes zoster

EXPLANATIONS:

(u) A. The lesions of bullous pemphigoid may be pruritic, but are not painful.(u) B. The lesions of contact dermatitis are not painful.(u) C. Pityriasis rosea usually occurs in children and young adults and is characterized by multiple pinkoval lesions that are scattered symmetrically, with a Christmas tree like distribution over the trunk.(c) D. Herpes zoster presents with painful vesicular rash in dermatomal distribution.REF: (16)

c = Correct u = Unsatisfactorya = Acceptable h = Potentially harmful

72. 3. DIAGNOSIS A 6-year-old girl is brought in by her mother, who is concerned about sores located on the girl’s face. Initially, the lesion was described as a “cold sore,” but recently it has spread and developed a crusty appearance. On examination, small erosions covered by moist, honey-colored crusts are noted. Themost likely diagnosis is

A. impetigo.

B. psoriasis.

C. atopic dermatitis.

D. allergic contact dermatitis.

EXPLANATIONS:

(c) A. The vesiculopustular form of impetigo is characterized by golden-crusted lesions.(u) B. Psoriasis is characterized by silvery scales on bright red, well-demarcated plaques.(u) C. Atopic dermatitis is characterized by pruritic, exudative, or lichenified eruptions.(u) D. While allergic contact dermatitis presents with vesicular lesions and may go on to form crusts,honey-colored crusts are classically a finding of impetigo.REF: (12)

73. 3. DIAGNOSISA 72-year-old male presents to the clinic for evaluation of a bump on his nose. The patient is a lifelongresident of Florida and an avid golfer. On examination, a 1 cm round, firm, pearly nodule with finetelangiectasias is noted. Which of the following is the most likely diagnosis?

A. basal cell carcinoma

B. squamous cell carcinoma

C. seborrheic keratosis

D. actinic keratosis

EXPLANATIONS:

(c) A. The lesion of basal cell carcinoma is typically firm, round, and pearly or waxy. It is the most common cutaneous neoplasm in humans, with 85% of them occurring on the head or neck. Margintelangiectasis are classically associated with basal cell carcinomas. Risk factors include fair skin,excessive sun exposure, and male gender.(u) B. Lesions of squamous cell carcinoma vary in appearance, but do not have overlyingtelangiectasias.(u) C. The lesions of seborrheic keratosis demonstrate a well-circumscribed border, have a stuck-onappearance, and are a variable tan-brown-black color.(u) D. Lesions of actinic keratosis are 3-6 mm in size, have a rough texture, with eventual formation of ayellow adherent crust. These lesions are found in sun-exposed areas and may be consideredpremalignant.REF: (16)

c = Correct u = Unsatisfactorya = Acceptable h = Potentially harmful

74. 3. DIAGNOSISA patient presents with fatigue, weakness and weight loss. On examination, his blood pressure is 90/60mm Hg, and there is hyperpigmentation of skin creases, pressure areas, and nipples. Plasma ACTH level is elevated. The most likely diagnosis is which of the following?

A. thyrotoxicosis

B. hypothyroidism

C. Cushing’s disease

D. Addison’s disease

EXPLANATIONS:

(u) A. Thyrotoxicosis, hypothyroidism and Cushing’s disease may present with vitiligo, ahypopigmentation disorder, not hyperpigmentation.(u) B. See A for explanation.(u) C. See A for explanation.(c) D. This is a classic presentation of Addison’s disease, lack of inhibitation of MSH leads tohyperpigmentation.REF: (16)

75. 3. DIAGNOSISA 58-year-old chemotherapy patient presents with fever, chills, productive cough, and disorientation.The patient appears very ill. Vital signs include:T 102°FP 138/minR 24/minBP 70/40 mm HgLaboratory results include:WBC 2.1 x 103 /mm3 Na 140 mEq/LCI 90 mEq/LHCO3-15 mEq/LGlucose 140 mg/dLBesides sepsis, the most likely diagnosis is

A. lactic acidosis.

B. hyperglycemia.

C. hyperchloremia.

D. blast crisis.

EXPLANATIONS:

(c) A. Lactic acidosis is the most common cause of anion gap acidosis. In a patient with inadequatetissue perfusion, lactic acid builds up due to anaerobic metabolism, leading to accumulation of an”unmeasured ion.”(u) B. The glucose level is only mildly elevated and would not constitute hyperglycemia.(u) C. The chloride is low, not elevated.(u) D. Severely elevated WBC with blast forms would most likely accompany a blast crisis.REF: (7)

c = Correct u = Unsatisfactorya = Acceptable h = Potentially harmful

76. 3. DIAGNOSISA 72-year-old patient with Type 2 diabetes treated with glyburide is brought into the clinic by herdaughter, who provides the patient’s history. The patient has had a mild fever, sore throat, andexcessive diuresis for the past 2 days. She has been reluctant to eat or drink because of the sore throat.At the clinic, she becomes increasingly stuporous and lethargic. Based on this information, the patient ismost likely experiencing

A. a diabetic ketoacidosis.

B. a nonketotic hyperglycemic hyperosmolar state.

C. hypoglycemia secondary to her refusal to eat.

D. lactic acidosis secondary to an infectious process.

EXPLANATIONS:

(u) A. Diabetic ketoacidosis is usually preceded by a day or more of polyuria and polydipsia in association with nausea and vomiting in someone receiving insulin. (c) B. A nonketotic hyperglycemic hyperosmolar coma is most common in an elderly patient with mild diabetes. Lethargy and confusion develop as osmolality rises to 300 mosm/kg or higher.(a) C. Although hypoglycemia induced by oral glucose lowering agents is less common, it tends tooccur in elderly patients with impaired renal function and is generally associated with longer acting sulfonylureas.(u) D. Lactic acidosis is a possibility, but is often associated with a severe infectious process, which isnot definite in this patient.REF: (9)

77. 3 DIAGNOSISA 2-year-old child presents to the emergency department with increasing respiratory distress. Themother states that the child had a “cold” 2 weeks ago. Last week the cough progressed and is describedas barky in nature, associated with stridor. The child appeared to be getting better, but last night,developed a fever and increased respiratory distress. Physical examination reveals a temperature of102°F. The child is in moderate respiratory distress. A portable lateral neck x-ray film reveals severesubglottic and tracheal narrowing. Which of the following is the most likely diagnosis?

A. acute epiglottitis

B. bacterial tracheitis

C. acute spasmodic croup

D. laryngotracheobronchitis

EXPLANATIONS

(h) A. While acute epiglottitis usually presents with respiratory distress and high fever, it is also typicallyassociated with dysphagia and drooling. Findings on a lateral neck x-ray film would be consistent withswelling of the epiglottitis described as a “thumbprint”sign.(c) B. Bacterial tracheitis usually presents following a viral upper respiratory infection, especiallylaryngotracheobronchitis (croup). It should be suspected when a patient develops high fever andrespiratory distress after a few days of apparent improvement or if the patient fails to respond to the usualtreatment for croup. The findings of subglottic and tracheal narrowing on the lateral neck x-ray film highlysupport this diagnosis.(h) C. Acute spasmodic croup is clinically very similar to acute laryngotracheobronchitis, but the patient isusually afebrile and the lateral neck x-ray film would be unremarkable.(h) D. See C for explanation.REF: (12)

c = Correct u = Unsatisfactorya = Acceptable h = Potentially harmful

78. DIAGNOSISA 62-year-old male with Type 2 diabetes presents complaining of left ear pain and drainage for the past 2weeks. He states the pain is deep in the ear and that the drainage is greenish and foul-smelling and hasincreased over the past 2 weeks. He denies cough, congestion, fever, or placing anything in his ear. Onphysical examination, the patient is afebrile. Otoscopic examination reveals a markedly edematous leftear canal draining purulent, green discharge. The tympanic membrane is unable to be visualized.Examination of the right ear is unremarkable. Which of the following is the most likely diagnosis?

A. auricular cellulitis

B. acute mastoiditis

C. chronic otitis externa

D. malignant otitis externa

EXPLANATIONS:

(h) A. Auricular cellulitis usually presents with swelling, erythema, and tenderness of the ear, primarily involving the lobule of the ear. There would not be any associated otorrhea. (h) B. Acute mastoiditis presents with pain, tenderness, and swelling over the mastoid. This canaccompany an untreated acute otitis media, but is now rare with prompt antibiotic treatment of acute otitismedia.(h) C. Chronic otitis externa presents primarily with pruritus and rarely is associated with ear pain. It isusually caused by irritation from repeated minor trauma to the ear canal or drainage from a chronicmiddle ear infection.(c) D. Malignant (invasive) otitis externa is seen primarily in patients with diabetes. It usually presentswith ear pain and drainage present for several weeks to months. Physical examination findings includean edematous ear canal with the presence of granulation tissue in the posterior wall at the mid-portion ofthe canal. Fever is rare. Accurate diagnosis is needed for this patient as this is a potentially life-threatening infection.REF: (9)

79. 3. DIAGNOSISA patient presents with progressive hearing loss, tinnitus, and vertigo. Which of the following is the probable diagnosis?

A. Ramsay Hunt syndrome

B. presbycusis

C. Meniere’s syndrome

D. vestibular neuronitis

EXPLANATIONS:(u) A. Ramsey-Hunt syndrome is caused by herpes zoster. It presents with facial palsy, lesions of the external ear, vertigo, tinnitus, and deafness.(u) B. Presbycusis is sensory hearing loss associated with aging. Tinnitus and vertigo are not associatedwith presbycusis.(c) C. Meniere’s syndrome is associated with the triad of hearing loss, vertigo, and tinnitus. It results from the distention of the endolymphatic compartment of the inner ear.(u) D. Vestibular neuronitis is characterized by vertigo without any loss of hearing.REF: (16)

c = Correct u = Unsatisfactorya = Acceptable h = Potentially harmful

80.A patient presents complaining of “yellow vision”. The physician assistant noticed a small, central lensopacity on her last visit that seems to have enlarged. The most likely diagnosis is which of the following?

A. cataract

B. pterygium

C. keratitis

D. glaucoma

EXPLANATIONS:(c) A. Nuclear cataract presents with slowly progressive visual loss with a yellow discoloration to vision.(u) B. Pterygium is a small, raised conjunctival nodule at the temporal or nasal limbus that encroaches onthe corneal surface.(u) C. Keratitis is inflammation of the cornea.(u) D. Glaucoma leads to gradual loss of peripheral vision.REF:

81. 3. DIAGNOSIS An 89-year-old female presents with a diagnosis of chronic open-angle glaucoma which has been well controlled until recently, when topical beta-adrenergic blocker eye drops were prescribed. She is now complaining of fatigue, generalized weakness, and dizziness. Which of the following is the most likely etiology of these symptoms?

A. depression

B. the eye drops

C. glaucoma

D. advanced age

EXPLANATIONS: (u) A. Depression may present with weakness, fatigue, and dizziness, but the recent addition of the beta-blockers would explain the new symptoms.(c) B. Topical beta-blockers may be absorbed systemically, decreasing the heart rate, resulting in a decrease in cardiac output. This process would cause these symptoms.(u) C. Glaucoma would not be associated with these symptoms.(u) D. The patient’s advanced age alone would not account for these symptoms.REF: (30)

c = Correct u = Unsatisfactorya = Acceptable h = Potentially harmful

82. 3. DIAGNOSISA 60-year-old male presents with a recent history of change of bowel habits, weight loss, and blood and mucus in his stools. The most likely diagnosis is

A. hemorrhoids.

B. colorectal carcinoma.

C. acute diverticulitis.

D. fistula-in-ano.

EXPLANATIONS:(u) A. Hemorrhoids may present with blood noted in the stool, but is not accompanied by weight loss.(c) B. Colorectal cancer presents with weight loss, change of bowel habits, and blood in stool.(u) C. Acute diverticulitis presents with abdominal pain and tenderness, fever, and peritoneal findings.(u) D. Patients with fistula-in-ano presents with severe pain, and there may be blood in the stool, butweight loss is not seen.REF: (7)

83. A 52-year-old female presents with diffuse abdominal pain accompanied by distention and visible peristalsis. Auscultation reveals hyperactive bowel sounds. Percussion is tympanic throughout.Palpation reveals mild diffuse tenderness without masses. The most likely diagnosis is

A. intra-abdominal abscess.

B. intestinal obstruction.

C. paralytic ileus.

D. cholecystitis.

EXPLANATIONS: (u) A. An intra-abdominal abscess would be accompanied by fever and localized tenderness.(c) B. Intestinal obstruction without complications is suggested by crampy pain, abdominal distention,hyperactive bowel sounds, visible peristalsis, and minimal tenderness.(u) C. Bowel sounds in paralytic ileus are absent.(u) D. Cholecystitis is accompanied by localized pain and tenderness.REF: (24)

c = Correct u = Unsatisfactorya = Acceptable h = Potentially harmful

84. Marked hypersecretion, gastric hyperacidity, and persistent ulcers are associated with which of the following?

A. Zollinger-Ellison syndrome

B. Peutz-Jeghers syndrome

C. hyperthyroidism

D. hypercalcemia

EXPLANATIONS:(c) A. Gastrin-producing islet cell tumors stimulate hypersecretion of gastric acid with resultant severe peptic ulcers as indicated in Zollinger-Ellison syndrome.(u) B. Peutz-Jeghers syndrome is a rare, autosomal dominant syndrome characterized by multiple hamartomatous polyps scattered throughout the entire gastrointestinal tract.(u) C. Hyperthyroidism is associated with increased thyroid hormone secretion, leading to increased metabolic rate, tachycardia, hyper reflexia, weight loss, and other symptoms, but not ulcers.(u) D. Hypercalcemia is associated with nephrolithiasis, cardiac conduction abnormalities, and other metabolic abnormalities, but not ulcers.REF: (9)

85. Infants who consistently choke and cough or become cyanotic with feeding should be evaluated for the presence of

A. achalasia.

B. pyloric stenosis.

C. lactose intolerance.

D. tracheoesophageal fistula.

EXPLANATIONS: Ref 5(u) A. Achalasia is manifested by dysphagia, regurgitation of food, cough, and failure to gain weight. It is rare under the age of 4 years old.(u) B. Pyloric stenosis is manifested by progressive vomiting that occurs immediately after a feeding.(u) C. Lactose intolerance is manifested by explosive watery diarrhea associated with abdominal distension, borborygmi, flatulence, and an excoriated diaper area.(c) D. These symptoms are consistent with tracheoesophageal fistula due to the connection between the trachea and esophagus.REF:(5)

86. 20-year-old male presents with a mass in the groin. On inspection with the patient standing a symmetric, round swelling is noted at the external ring. When the patient lies down the mass disappears. The patient denies any trauma. The most likely diagnosis is

A. an indirect inguinal hernia.

B. a direct inguinal hernia.

C. an obturator hernia.

D. a femoral hernia.

EXPLANATIONS:(u) A. An indirect inguinal hernia is typically elliptic that does not reduce easily.(c) B. A direct inguinal hernia is symmetrical, round and disappears easily with the patient lying down.(u) C. An obturator hernia is more commonly seen in elderly women and are rarely palpable in the groin.(u) D. Femoral hernias are rare in males and do not typically reduce with lying down.REF: (31)

87. A preterm neonate was doing well initially until 6 days postpartum. At this time, the neonate exhibited increasing lethargy and poor feeding associated with temperature instability, hypotonia, and increasing periods of apnea. Which of the following is the most likely diagnosis?

A. phenylketonuria

B. bacterial sepsis

C. congenital syphilis

D. hepatitis B infection

EXPLANATIONS: (u) A. Phenylketonuria presents with vomiting, irritability and convulsions. No changes in temperature or apnea are noted.(c) B. Late-onset bacterial infections presenting after 5 days of age exhibit the subtle signs and symptoms noted. This diagnosis must be considered and appropriately evaluated.(u) C. In the newborn period, neonates with this condition are most often asymptomatic. Diagnosis is made by maternal and infant serologic testing and is only presumptive.(u) D. Infants are infected with hepatitis B at the time of birth. Clinical illness is rare in the neonatalperiod.REF: (12)

88. A 40-year-old patient presents with fever, night sweats, and a 3 cm, nontender lymph node in the neck.Chest x-ray shows mediastinal adenopathy. The most likely diagnosis is

A. chronic lymphocytic leukemia.

B. hairy cell leukemia.

C. multiple myeloma.

D. Hodgkin’s disease.

EXPLANATIONS:(u) A. Chronic lymphocytic leukemia may present with lymphadenopathy, but B-symptoms (fever, nightsweats, and weight loss) are not commonly seen. The chest x-ray is typically normal.(u) B. Hairy cell leukemia is commonly seen in older males. Lymphadenopathy is minimal and chest x-ray is normal.(u) C. Multiple myeloma presents with bone pain and lymphadenopathy is not seen.(c) D. Hodgkin’s disease typically presents with nontender lymphadenopathy in the neck and axilla andB-symptoms. Mediastinal adenopathy is also common.REF: (9)

89. An 8-year-old boy is admitted for “seizures” that are described as “20-second lapses of awareness”when he blinks his eyes. After these attacks, he resumes his previous activity. Which of the followingseizure types is most likely?

A. tonic-clonic

B. myoclonic

C. absence

D. focal

EXPLANATIONS:(u) A. Tonic-clonic seizures are associated with a loss of consciousness, tonic-clonic movements, andpostictal confusion or sleep.(u) B. Myoclonic seizures are associated with mild myoclonic jerks of the neck and shoulder flexor muscles after waking up.(c) C. Absence seizures are characterized by lapses of consciousness associated with postictal confusion.(u) D. Focal seizures are associated with motor or sensory symptoms involving any portion of the body.REF: (12)

90. 32-year-old female presents with a 7-month history of recurrent, brief episodes of weakness and tingling in the extremities, diplopia, and vertigo. The most likely diagnosis is

A. Guillain-Barré syndrome.

B. myasthenia gravis.

C. multiple sclerosis.

D. amyotrophic lateral sclerosis.

EXPLANATIONS:(u) A. Guillain-Barré syndrome typically presents with progressive weakness that starts peripherally and proceeds centrally over a brief period of time.(u) B. Myasthenia gravis presents with weakness and fatigue in the upper limbs, cranial, and/or trunk musculature. Blurry vision and diplopia are common visual complaints and dysphagia is common.(c) C. Multiple sclerosis is most frequently seen in patients in their twenties and presents with episodes of weakness, paresthesias, and diplopia.(u) D. Amyotrophic lateral sclerosis presents with progressive weakness, fasciculations, and loss of muscle mass.REF:

91. A 50-year-old male presents with a 3-month history of weakness, cramping, fasciculations, and loss of muscle mass in his left arm. The most likely diagnosis is

A. amyotrophic lateral sclerosis.

B. Guillain-Barré syndrome.

C. Parkinson’s disease.

D. myasthenia gravis.

EXPLANATIONS:(c) A. The most common acquired motor neuron disease is amyotrophic lateral sclerosis. It is a disorder of both upper and lower motor neurons, leading to a complex clinical syndrome that includes painless,progressive weakness, muscle atrophy, fasciculations, muscle cramps, spasticity, and clonus.(u) B. Guillain-Barré syndrome presents with progressive weakness that starts peripherally and progresses centrally over a generally brief period of time.(u) C. Bradykinesia, cogwheel rigidity, postural instability, propulsion/retropulsion, and resting tremor arecharacteristic findings in Parkinson’s disease.(u) D. Myasthenia gravis is an autoimmune disorder that is marked by weakness and fatigue in the upperlimbs, cranial and/or trunk musculature. Ocular signs and symptoms include diplopia, ptosis, and blurredvision. Dysphagia is a frequent presenting complaint.REF: (7)

92.A 15-year-old female is seen for routine prenatal care at 28 weeks’ gestation. She denies any complaints, but has noted some increase in dependent edema and her ring appears tight in the morning.Her PMHx is unremarkable. Physical examination reveals VS: P – 82 reg; R – 20 unlabored; BP – 126/90mm Hg. She has gained 10 lbs since her last routine visit. Fundal height is consistent with 26.5 weekswith reactive fetal heart tones. +1/4 pedal edema is present bilaterally and DTRs are +3/4 bilaterally.Dipstick of urine reveals trace protein. The most likely diagnosis is

A. eclampsia.

B. pre-eclampsia.

C. chronic hypertension.

D. transient hypertension.

EXPLANATIONS: Ref 14(u) A. Eclampsia would include the onset of seizures in a pre-eclamptic patient which are not accountedfor by any other cause.(c) B. The classic findings of edema, especially involving the hands or face in the morning, hypertension,and proteinuria are most consistent with pre-eclampsia, which is more common in the first pregnancy andmore frequent in adolescent over adult pregnancies.(u) C. Chronic hypertension is defined as hypertension present prior to conception, before 20 weeks’gestation, or that persists for greater than 6 weeks postpartum.(u) D. Transient hypertension is defined as development of hypertension after mid pregnancy or in thefirst 24 hours postpartum, but the other signs and symptoms of pre-eclampsia or pre-existinghypertension are absent.REF: (27)

93. A woman who is late in her last trimester presents in the emergency department with bright, red vaginal bleeding with no abdominal pain. Her blood pressure is 120/80 mm Hg. The most likely diagnosis is

A. spontaneous abortion.

B. placenta previa

.C. hydatidiform mole.

D. abruptio placentae.

EXPLANATIONS:(u) A. Spontaneous abortion presents with pain and delivery of all or any part of the products ofconception before the 20th completed week of gestation.(c) B. Placenta previa presents sudden painless, profuse bleeding in the third trimester.(u) C. Hydatidiform mole presents with 1st trimester bleeding and hyperemesis.(u) D. Abruptio placentae presents with abdominal or back pain and bleeding may not be evident.REF: (27)

94. A 10-year-old male presents with pain in his left leg that is worse at night. Aspirin relieves the pain andthe patient denies injury. On examination, there is point tenderness over the tibia, and the patient has aslight limp that favors the left leg. Radiographs show a 1 cm radiolucent nidus surrounded byosteosclerosis. The most likely diagnosis is

A. osteosarcoma.

B. bone cyst.

C. osteoblastoma.

D. osteoid osteoma.

EXPLANATIONS:(u) A. Osteosarcoma and Ewing sarcoma are malignant bone tumors that present with pain and swelling.No improvement is noted with conservative therapy.(u) B. Bone cysts are not symptomatic.(u) C. Osteoblastoma is benign and typically involves the spine. Pain is dull and aching with no change at night.(c) D. Osteoid osteoma is a benign tumor in children age 5 to 20, presents with increasing pain, worse at night and relieved by aspirin.REF: (7)

95. An 18-year-old patient has a tibia/fibula fracture following a motorcycle crash. Twelve hours later the patient presents with increased pain despite adequate doses of analgesics and immobilization. Which ofthe following is the most likely diagnosis?

A. avascular necrosis

B. myositis ossificans

C. compartment syndrome

D. reflex sympathetic dystrophy

EXPLANATIONS:(u) A. Avascular necrosis occurs primarily in muscles post-traumatically and may not arise for severalmonths after an injury.(u) B. Myositis ossificans is a late complication of fracture resulting from disruption of the blood supply tothe bone.(c) C. Compartment syndrome is characterized by a pathological increase of pressure within a closed space and results from edema or bleeding within the compartment. It may occur as an early local complication of fracture.(u) D. Reflex sympathetic dystrophy is characterized by painful wasting of the hand muscles that may besecondary to injury and could occur as a late complication.REF: (31)

96. A 14-year-old patient who fell on his outstretched hand, now complains of pain along the entire arm. There is point tenderness just proximal to the wrist and also over the proximal ulna. There is significant pain with movement of the elbow joint. An x-ray will most likely show a

A. Galeazzi’s fracture/dislocation.

B. Monteggia’s fracture/dislocation.

C. Colles’ fracture.

D. Smith’s fracture.

EXPLANATIONS:(c) A. Galeazzi’s fracture/dislocation involves a fracture of the distal radial shaft with proximal radioulnar joint disruption and subluxation of the proximal ulna.(u) B. The Monteggia’s fracture is a proximal ulna fracture with a concomitant dislocation of the radialhead.(u) C. A Colles’ fracture of the distal radius has a characteristic “silver fork” deformity, but does not involve the elbow joint.(u) D. A Smith’s fracture is the reverse of a Colles’ fracture, with volar angulation of the distal radius, but does not involve the elbow joint. REF: (24)

97. A 26-year-old woman complains of a lack of energy and decreased sleep at night. Her lack of sleep has interfered with her work and social activities. She awakens several times each night and checks her doors and windows to ensure they are closed and locked. This is an example of

A. agoraphobia

B. alcohol abuse.

C. obsessive-compulsive disorder

.D. panic disorder.

EXPLANATIONS:(u) A. Agoraphobia is the fear of being alone in public places. This person does not display thischaracteristic.(u) B. There is no evidence of alcohol abuse.(c) C. This person displays a compulsive behavior by reassuring herself that the doors and windows arelocked and secure, thereby her anxiety regarding her safety is reduced. This behavior is resulting ininterference with her normal daily routine.(u) D. A panic disorder is characterized by a brief period of anxiety and fear, accompanied by somaticsymptoms, such as palpitations and tachypnea.REF: (13)

98. A person who witnessed the World Trade Towers attack complains of sleep disturbances associated with recurrent distressing dreams of the attacks, withdrawal from friends, sensations of foreboding on the anniversary date, and depression. This person is most likely suffering from

A. major depressive disorder.

B. post traumatic stress disorder.

C. generalized anxiety disorder.

D. dysthymic disorder.

EXPLANATIONS:(u) A. Although there are some similarities between this and a major depressive disorder, there is no display of feelings of guilt, diminished concentration, fatigue or loss of energy, significant weight loss, or recurrent thoughts of death, as characteristic of major depressive disorder.(c) B. This is a classic presentation for post-traumatic stress disorder, when a person has experienced an event that would be traumatic to almost anyone. All of this person’s complaints are characteristic of PTSD.(u) C. Generalized anxiety disorder displays restlessness, easy fatigability, difficulty in concentrating, irritability, sleep disturbances or muscle tension (3 of these 6 are required) associated with anxiety and worry.(u) D. For a diagnosis of dysthymic disorder, the person must display, while depressed, 2 or more of the following: an eating disturbance, sleep disturbances, low energy or fatigue, low self-esteem, changes in concentration or indecisiveness, and feelings of hopelessness.REF: (13)

99. Chest x-ray of a 63-year-old smoker reveals a hilar mass, mediastinal widening, and cavitation. Which of the following is the most likely diagnosis?

A. squamous cell carcinoma

B. adenocarcinoma

C. mesothelioma

D. large cell tumor

EXPLANATIONS:(c) A. Squamous cell carcinoma commonly produces a hilar mass, mediastinal widening, and cavitation.(u) B. Adenocarcinoma produces small peripheral masses.(u) C. Mesothelioma presents with pleural thickening.(u) D. Large cell tumors produce large peripheral masses.REF: (16)

CLINICAL THERAPEUTICS

100.Which of the following is the only therapy that is documented to alter the natural history of COPD?

A. bronchodilators

B. corticosteroids

C. oxygen

D. chronic antibiotic use

EXPLANATIONS:(u) A. Bronchodilators do not alter the inexorable decline in lung function that is the hallmark of the disease, but they offer improvement in symptoms, exercise tolerance, and overall health status.(u) B. COPD is not generally a steroid-responsive disease, apart from acute exacerbations. Only 10% of stable outpatients with COPD given oral corticosteroids have a greater than 20% increase in FEV1, compared to patients receiving placebo.(c) C. Oxygen is the only therapy that is documented to alter the natural history of COPD in those patients with resting hypoxemia. Home oxygen therapy in advanced COPD includes longer survival,reduced hospitalization, and better quality of life.(u) D. Chronic antibiotic use will have no effect on the natural history of COPD.REF: (16)

101. A firefighter is brought into the emergency room from a fire with a complaint of headache, dizziness, and abdominal pain. The odor of bitter almonds is noted on the patient’s breath. The best treatment for this patient is which of the following?

A. atropine

B. pyridoxine

C. deferoxamine

D. sodium nitrite

EXPLANATIONS: (u) A. Atropine is used in treating organophosphate poisoning.(u) B. Pyridoxine is used in treating isoniazid overdose.(u) C. Deferoxamine is used in treating iron overdose.(c) D. This patient presents with typical findings of cyanide poisoning. This is best treated with sodium nitrite.

102. Which of the following hypertensive medications should be avoided in patients with asthma?

A. diltiazem (Cardizem)

B. propranolol (Inderal)

C. amlodipine (Norvasc)

D. metolazone (Zaroxolyn)

EXPLANATIONS:(u) A. Diltiazem is a calcium channel blocker that acts by causing peripheral vasodilation. There is noeffect on asthma.(c) B. Propranolol is a beta blocker that may block bronchodilation produced by endogenous and-exogenous catecholamine stimulation of beta receptors.(u) C. Amlodipine is a calcium channel blocker. See A for explanation. (u) D. Metolazone is a diureticthat lowers blood pressure initially by decreasing plasma volume and cardiac output. There is no effecton asthma.REF: (16)